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Partial nephrectomy

Indications for partial nephrectomy:

  • Tumour in solitary kidney
  • Bilateral renal tumours
  • Hereditary syndromes
  • Chronic kidney disease or limited renal reserve
  • “Elective” – small renal mass with normal renal function and normal contra-lateral kidney

 

Considerations:

Hyperfiltration injury

  • Renal blood flow delivered to fewer nephrons – increased glomerular capillary perfusion pressure and single nephron GFR. Over decades, nephrons injured by hyperfiltration leading to focal segmental glomerulosclerosis when the total nephron mass is reduced by > 80 %.

Renal ischaemic time

  • Either regional ischaemia (selective clamping) or global ischaemia. Also warm ischaemia vs cold ischaemia (ice slush) – can tolerate longer clamp times with cooling.
  • 12.5 mg intravenous mannitol and 40 mg Lasix prior to clamping may theoretically reduce ischaemic injury although not definitively proven.

 

Consent / complications:

Intra-op:

  • Bleeding – transfusion, conversion to nephrectomy
  • Conversion to nephrectomy due to inability to safely complete partial
  • Pleural injury and chest transgression
  • Bowel injury
  • Spleen/liver/duodenum injury
  • GA risks

Post-op:

  • Bleeding from resection, or AVM/pseudoaneurysm – requiring IR, or return to OT +/- nephrectomy
  • Urine leak requiring further procedures
  • Wound issues – hernia, infection, flank bulge
  • Pain and persisting neuropathic pain
  • DVT/PE

 

 

Positive margins:

  • 2 – 8 %
  • More frequency in imperative partials, and those with adverse pathological features (pT2+, grade 3-4)
  • 16 % rate of local recurrence vs 3 % for clear margins – therefore proceeding to radical nephrectomy or re-do partial will be significant overtreatment for many.
    • Patients should be informed they are at higher risk for recurrence, and may need more intensive imaging surveillance
  • Meta-analyses of retrospective studies are conflicting – but upstaged pT3a tumours with positive margins seem to have worse prognosis and mortality

 

Approach for open:

  • Retroperitoneal flank approach preferred – subcostal lacks exposure to hilum and upper pole, transperitoneal risks urine leak and bleeding intraperitoneally
  • Supra-11 or supra-12/tip of 12th incision ideal – supra-11 if upper pole tumour.

 

Technique:

  • GA, lateral position with break at flank
  • Above rib to avoid neurovascular bundle – continuing to edge of rectus
  • Divide lat dorsi and serratus posterior behind costal margin, external and internal oblique anteriorly
  • Open the lumbodorsal fascia at the tip of the rib sharply, avoiding pleura and peritoneum
  • Divide TA and sweep peritoneum medially
  • Expose diaphragm above – sweep/mobilise pleura superiorly
  • Divide intercostal muscles as far back as needed on superior aspect of rib
  • Develop the retroperitoneal space and use a fixed table retractor
  • Mobilise the kidney posteriorly and laterally
  • Identify the hilum – either tracing up gonadal vein or IVC – and sling the vessels
    • If artery is not easily visible, may need to further mobilise and ‘flip’ kidney to identify and sling from behind
  • Undress the kidney, opening Gerota’s and mobilising peri-nephric fat over tumour to expose – can use Rampley’s on the fat
  • Score the tumour with diathermy and ultrasound the get a feel for the extension
  • Bulldog clamp on artery +/- vein (or use slings; or use hand to compress the kidney)
  • Excise tumour – can fracture the plane with Metz, or use diathermy
    • Assistant using Frazier suckers
  • Close any collecting system breach with 4-0 PDS
  • Overrun the base with 3-0 stratafix or V-loc
  • Clamps off
  • Fibrillar and Floseal to base and compress with a wet Raytec for a few minutes
  • Oversew any bleeding points figure of 8 3-0 PDS
  • Sliding clip renorrhaphy second layer – 1-vicryl – Hem-o-lok on tail – through each parenchymal edge +/- including perinephric fat – clip on other end and snug down, careful not to pull through
  • Cover with perinephric fat
  • Drain
  • Mass closure or closure in 2 layers – can unbreak the table and use interrupted 0 vicryls if needed

Bleeding:

  • If brisk arterial bleeding on parenchymal incision – either missed artery or dodgy clamp
  • If ongoing parenchymal venous bleeding – can take off venous clamp to reduce engorgement, or compress kidney with hand
  • Consider haemostatic agents like Tachosil

Excise 11th rib:

  • If needed – scrape periosteum off bone with periosteal elevator / osteotome then circular rib stripper, pulling periosteum anteriorly to tip of rib
  • Use rib cutter with blade as far posterior as needed
  • Bone wax if needed for bleeding cut edge

Pleural injury:

  • Repair with 3-0 PDS (monofilament given delicacy) – tie on Valsalva / positive pressure expiration
  • Consider drain if large complex injury

Urine leak:

  • Will generally settle with time and leaving drain – sit tight if no infection, and not single kidney leaking
  • If forced to place stent, need catheter as well to minimise reflux